PDF《入院安排 Admission Arrangement》

NUA-046m-18-777(R19) MR 入院安排 Admission Arrangement 提示: 如病人是次入院需要接受手术或外科程序,请填写「NUA-532m」代替此表格 Reminder: If an operation or surgical procedure is required during hospitalization, please fill in "NUA-532m" instead of this form 姓名 Name 年龄/性别 Age / Sex *香港身份证号码 / 护照号码 *HKID / Passport No.

联络电话 Contact Phone No. 1. 请於________年________月________日*(上午/下午)时到达医院大楼地下入院部办理入院手续 Please arrive at the Admission Office on G/F, Main Hospital Building for registration on at am/pm) 2. 请於________年________月________日*(上午/下午/午夜)时后,不要 进食和饮水 Please DO NOT eat or drink on at am/pm/12mn) 3. 温馨提示 Warm Reminder: ? 已向客人提供「NUA-392mc/sc 入院前提示」作参考 ? Provide "NUA-392me Information for Clients Before Admission" to client for reference 4. 选择之房间类别: ? 标准房 (四至十四人房) ? 半私家房 ? 私家房(房租 ? 育婴室 本院将尽量按客人意愿安排房间,但最终安排要按客人入院时本院的房间供应而定.若届时客人选择的房间类别已满,本院将会 安排客人入住其他类别的房间,并按客人所入住房间类别收取费用 (私家房除外). Preferred Room Type: ? Standard Room (4-14 Bedded) ? Semi-private Room ? Private Room (Room Charges ? Nursery Union Hospital will do our utmost to arrange the room according to the client's choice, but the final arrangement will depend on the availability of rooms upon admission. If the selected room class is not available, client will be assigned to alternative class and be charged with the room class admitted (except private room). 入院原因 Reason for Admission 医生处方 Doctor's Prescription 检查项目 Investigation 已知致敏物质 Known Allergy 医生签署 Doctor's Signature 医生姓名 v请用正楷w Name in BLOCK Letter 医生编号 Code No. 日期 Date Pre-Admission Screening (Fill out by nursing staff / doctor): Completed Form NUA-428 to conduct: Active MRSA Screening Programme Assessment ? No ? Yes Please refer to Infection Control Manual C Section 11.2.2 "Active MRSA Surveillance Programme for patient" & proceed to NUA-428 Active MRSA Screening Programme assessment History of Psychiatric Illness: ? No ? Yes If "Yes", please refer to GNWG(Psychiatric)(1) "Guideline on screening of Admission of Client with Psychiatric History" and proceed to NUA-306 Zung Self-Rating Depression Scale History of Pulmonary Tuberculosis: ? No ? Yes If "Yes", please refer to Infection Control Manual - Section 11.4.1 "Screening and Handling of Suspected / Confirmed Pulmonary TB case" & fill in NUA-371 if booking of surgery is required Creutzfeldt C Jakob Disease Risk Assessment ? N/A ? No ? Yes If "Yes", please refer to Infection Control Manual C Section 11.8 "Transmissible Spongiform Encephalopathies (TSEs) and GNWG (Infection Control) (6) "Workflow of doing the assessment to identify patient with or at increased risk of Creutzfeldt C Jakob Disease & fill in ICC-032 Assessment to identify patient with, or at increased risk of Creutzfeldt C Jakob Disease Special cultural need (e.g. translator, diet etc.) ? No ? Yes *客人 / 家属签署确认 Acknowledged by *Client / Next of kin: 关系 Relationship Completed by:Rank:Date: (Staff Signature & No.) 备注 Remarks: * 请删除不适用之项目 Please delete inappropriate item ? 请在合适的方格加上?号Please ? if applicable 香港沙田大围富健街十八号